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Hip Osteoarthritis

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Other Names

  • Osteoarthritis of the Hip
  • Hip OA
  • DJD of the Hip
  • Degenerative Joint Disease of the Hip


  • This page refers to Hip Osteoarthritis (Hip OA)



  • Prevalence
    • Jordan et al: symptomatic hip OA was reported at 9.2% among adults age 45 years and older, with 27% of the study population having radiographic evidence of disease[1]
    • Men have higher prevalence before age 50, women have higher prevalence after age 50
    • Highest in Caucasians (3-6%), estimated to be <1% in Asians, blacks, East Indians, or native Americans[2]
  • Incidence
    • Estimated at 88 per 100,000 person years (need citation)
  • CDC: Lifetime risk for symptomatic hip OA is 18.5% (men), 28.6% (women)[3]



  • Primary OA
    • Accounts for majority of hip OA
    • Idiopathic process
    • Not characterized by inflammatory process, rise in systemic inflammatory markers
    • Combination of genetic, age-related changes, mechanical stress and biomechanical factors
  • Secondary OA
  • Degenerative process
    • Characterized by progress loss of articular cartilage, mismatch between damage and repair
    • Cartilage damage occurs as a combination of biomechanical forces, biochemical factors
    • Subsequent reactive bone formation, osteophyte growth, bone remodeling
    • Para-articular tissues also involved
    • Hip OA results as a constellation of all these factors

Associated Conditions


  • Hip Joint
  • Hyaline Cartilage
    • Composed of chondrocytes embedded in extracellular matrix
    • Extracellular matrix composed of proteoglycans, including aggrecan, type II collagen

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • Patient course is most commonly insidious, worsening over time
    • Pain is in the hip or groin
    • Worse in the morning or after long periods of rest
    • Stiffness, which is often transient
    • Movement and activities that mobilize the joint may provide relief
    • Ask patient "do you have trouble putting on socks and shoes"?
  • Physical Exam: Physical Exam Hip
    • May see restriction and pain with internal and external rotation
    • Limited extension, flexion, internal rotation
  • Special tests



  • Standard Radiographs Hip
  • Findings
    • Joint space narrowing, which can be obliterated in end-stage disease
    • Osteophytes
    • Subchondral sclerosis
    • Subchondral cysts
    • Deformity of femoral head, acetabulum
  • Helpful to trend radiographs over time to monitor disease progression[10]
  • Altman et al: most sensitive diagnostic criteria is hip pain with two of the following[11]
    • ESR <20 mm/hr (not routinely tested)
    • Femoral or acetabular osteophytes
    • Joint space narrowing


  • Not required for diagnosis
  • May be indicated for pre-op planning or to exclude other etiologies
  • Helpful to get a better sense of bone structures and articular surface


  • Not required for diagnosis
  • May be indicated for pre-op planning or to exclude other etiologies
  • Helpful to evaluate the Acetabular Labrum, periarticular strucctures

Laboratory Evaluation

  • Generally not indicated unless secondary cause is implicated
  • Takahash et al: correlation between serum pyridinoline and tissue inhibitor of metalloproteinases 1 (TIMP-1) levels and the severity of OA assessed by the KL System[12]
    • Not commercially available but suggest future diagnostic and prognostic markers


Kellgren-Lawrence Classification

  • Grade 1[13]
    • Doubtful OA with possible joint space narrowing medially
    • Subtle osteophyte formation around the femoral head
  • Grade 2
    • Mild OA with definite joint space narrowing inferiorly
    • Definite osteophyte formation, slight subchondral sclerosis
  • Grade 3
    • Moderate OA with marked narrowing of the joint space
    • Small osteophytes, some sclerosis and cyst formation
    • Deformity of the femoral head and acetabulum
  • Grade 4
    • Obliterated joint space with features seen in grades 1 to 3, large osteophytes
    • Gross deformity of the femoral head and acetabulum

Tonnis Classification

  • Grade 0
    • Normal radiographs
  • Grade 1
    • Sclerosis of femoral head and acetabulum
    • Slight joint space narrowing
    • Slight lipping at joint margins
  • Grade 2
    • Small cysts in femoral head/acetabulum
    • Moderate joint space narrowing
    • Moderate loss of head sphericity
  • Grade 3
    • Large cysts in femoral head/acetabulum
    • Joint space obliteration/severe narrowing
    • Severe femoral head deformity vs. AVN





  • Patient Education
    • Helping patient understand disease process, empower them in their own care
    • Shown to decrease pain, improve quality of life in patients affected by OA[14]
  • Physical Exercise
    • Low-impact exercise is associated with reduction in pain[15]
    • Consider water-based or aquatic exercise therapy, which is also beneficial with less weight bearing[16]
    • Avoid exercises/ activities that provoke pain such as twisting, high impact sports (running)
    • Promote low impact activities such as yoga, cycling, swimming
    • Promote improved flexibility, stretching and range of motion
  • Physical Therapy
    • First line therapy for mild-moderate hip OA[17]
    • In patients with moderate-severe disease, PT is much less likely to be helpful
  • Weight Reduction
    • 10 lbs of weight gain is equivalent to 60 lbs of stress on the joint[18]
    • Weight loss is associated with reduction in cartilage loss, joint impact
  • Foot wear
    • Patients should be educated, encouraged to wear shoes with good shock absorbance, arch support
  • Assist Devices should be considered including
    • Walking sticks
    • Tap turners
    • Walking cane
    • Rolling walker

Pharmacologic Therapies

  • Acetaminophen
    • Literature is not great for acetaminophen[19], often used in conjunction with NSAIDS
    • Consider oral, topical
  • Capsaicin
    • Limited use due to joint depth
  • Opioids
    • Indicated in refractory cases, not first line therapy
  • Glucosamine, Chondroitin
    • Some benefit in reducing pain, no beneficial effects on function from knee OA literature
    • Evidence is underwhelming[20]
  • Needs to be updated/ researched


Joint Injections


  • Indications
    • Severe/ Kellgren grade 4
    • Refractory to conservative measures
  • Technique
    • Total Hip Arthroplasty (THA)
    • Hip Resurfacing
    • Arthroscopic Debridement (controversial)
    • Osteotomy
    • Femoral head resection

Rehab and Return to Play


  • Needs to be updated

Return to Play

  • Needs to be updated


  • Increased fall risk[22]
  • Chronic pain
  • Loss of function
  • Inability to return to work or sport

See Also


  1. Jordan JM, Helmick CG, Renner JB, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. 2009;36(4):809-815.
  2. 2.0 2.1 Brandt, Kenneth D., Paul Dieppe, and Eric L. Radin. "Etiopathogenesis of osteoarthritis." Rheumatic Disease Clinics of North America 34.3 (2008): 531-559.
  3. Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Adv Ther. 2016 Nov;33(11):1921–46. DOI:
  4. Ganz, R, Leunig, M, Leunig-Ganz, K, Harris, WH. The etiology of osteoarthritis of the hip. Clin Orthop Relat Res. 2008;466(2):264-272.
  5. Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev. 1988;10:1–28. DOI:
  6. MacGregor AJ, Antoniades L, Matson M, Andrew T, Spector TD. The genetic contribution to radiographic hip osteoarthritis in women: Results of a classic twin study. Arthritis Rheum. 2000 Nov;43(11):2410–6. DOI:
  7. Harris EC, Coggon D. Hip osteoarthritis and work. Best Pract Res Clin Rheumatol. 2015 Jun;29(3):462–82.
  8. Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former élite male athletes. BMJ. 1994 Jan 22;308(6923):231–4. DOI: https://doi.org/10.1136/bmj.308.6923.231. Erratum in: BMJ 1994 Mar 26;308(6932):819.
  9. Lanyon P, Muir K, Doherty S, Doherty M. Assessment of a genetic contribution to osteoarthritis of the hip: Sibling study. BMJ. 2000 Nov 11;321(7270):1179–83. DOI:
  10. Reijman M, Hazes JM, Pols HA, et al. Role of radiography in predicting progression of osteoarthritis of the hip: prospective cohort study. BMJ 2005;330:1183.
  11. Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505-14.
  12. Takahashi M, Naito K, Abe M, et al. Relationship between radiographic grading of osteoarthritis and the biochemical markers for arthritis in knee osteoarthritis. Arthritis Res Ther 2004;6:R208-12.
  13. Kellgren J. The Epidemiology of Chronic Rheumatism. Vol. 2. Oxford: Blackwell Scientific; 1963. Atlas of standard radiographs in arthritis.
  14. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip.American College of Rheumatology. Arthritis Rheum 1995;38:1535-40.
  15. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD007912. DOI:
  16. Bartels E, Juhl C, Christensen R, Hagen K, Danneskiold-Samsøe B, Dagfinrud H, Lund H. Aquatic exercise for the treatment of knee and hip osteoarthritis. 2016 Mar 23;3:CD005523. DOI:
  17. Zhang W, Doherty M, Arden N, et al. EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) Ann Rheum Dis. 2005 May;64(5):669–81.
  18. Reyes C, Leyland KM, Peat G, Cooper C, Arden NK, Prieto-Alhambra D. Association between overweight and obesity and risk of clinically diagnosed knee, hip, and hand osteoarthritis: A population-based cohort study. Arthritis Rheumatol. 2016 Aug;68(8):1869–75.
  19. Ennis, Zandra Nymand, et al. "Acetaminophen for chronic pain: a systematic review on efficacy." Basic & clinical pharmacology & toxicology 118.3 (2016): 184-189.
  20. Wandel S, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. (2010)
  21. He, Wei-wei, et al. "Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis." International Journal of Surgery 39 (2017): 95-103.
  22. ] S.G. Leveille, J. Bean, K. Bandeen-Roche, R. Jones, M. Hochberg, J.M. Guralnik, Musculoskeletal pain and risk for falls in older disabled women living in the community, J. Am. Geriatr. Soc. 50 (2002) 671–678.
Created by:
John Kiel on 5 July 2019 08:33:10
Last edited:
5 October 2022 13:05:44